The Possibility of Living with a Single Ventricle is Surprising

My comments on the excellent paper “Total Right Heart Bypass: Long-Term Complications and Survival” by Lafuente et al. (1) performed at the Hospital Garrahan, which is a proud heir of the glorious Hospital de Niños, are accompanied by nostalgic feelings. The article is even more meritorious as it was conducted at a public hospital attended by low-income population (generally living far away from the capital city) which is usually reluctant to answer questionnaires. The history of total right heart bypass (RHB) started in 1971 when Fontan (2) achieved survival with “ventricularization” of the right atrium (RA) in a tricuspid atresia (TA) by implanting a homograft in the atrial inlet and outlet using a Glenn shunt and closing the atrial septal defect. In the same year, and unaware of Fontan’s work, we performed an atriopulmonary anastomosis (APA) in a dying TA (3, 4) leaving a fenestration in the atrial septum and implanting a homograft between the RA and the pulmonary artery. After multiple deliberations with Rodríguez Coronel, Luis Becú and Eduardo Kreutzer, we formulated a different concept from that of Fontan, stating that ventricular end-diastolic pressure (VEDP) is the suction power source necessary to make the system work in the absence of obstruction in the pulmonary circuit. (5) Later, in 1978, we performed a posterior direct APA (6) behind the aorta, as large as possible, between the right atrium and the main pulmonary artery and its right branch, making a large APA to the appendage roof. This surgical technique became widely used worldwide and corresponds to group I: AP in the article by Lafuente et al. As the authors pointed out, atrial enlargement and arrhythmias can develop between 8 and 12 years after APA. The technique was surpassed in 1988 by the approach proposed by de Leval (7) and Castañeda (8) who developed the lateral tunnel which was not considered in the paper here commented. Then, in 1990 Marceletti (9) described the extracardiac conduit (EC) procedure which is mostly used in all the centers and represents group II: EC in the study by Lafuente et al. Adult cardiologists should not forget that right atrial pressure, and consequently venous pressure of at least 12 mm Hg is the premise of this peculiar